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Newsletter Article


Proposed Rule Would Give CMS Power to Drop Poor-Quality Plans

By John Reichard, CQ HealthBeat Editor

October 3, 2011 -- The Centers for Medicare and Medicaid Services (CMS) announced a proposed rule that would give the agency the power to drop Medicare Advantage plans and Medicare prescription drug coverage plans that get low marks for quality.

CMS could terminate plans that fail for three years to earn at least a three-star rating under the agency's five-star rating system.

The provision is part of a regulatory proposal for 2013 that also would put in place certain elements of the health care law (PL 111-148, PL 111-152).

For example, the proposal codifies the 50 percent discount on brand-name drugs prescribed for beneficiaries in the "doughnut hole"—the part of the Part D drug benefit in which beneficiaries are 100 percent responsible for their drug costs.

It also would expand covered drugs in Part D to include benzodiazepines and barbiturates for certain health conditions. Physicians could more easily appeal prescriptions denied by Part D plans.

"Special needs" plans serving people enrolled in both Medicare and Medicaid could offer certain extra benefits, such as nursing services in the home and food delivery to the homes of vulnerable beneficiaries, CMS said in a news release.

Prescribers could more easily order drugs for fewer than 30 days to help synchronize the times that multiple prescriptions are available for refill. The proposal also includes provisions to help fight fraud.

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